Delivering High-Quality Cancer Care: Can we meet the challenges of a

system in crisis?

Patricia A. Ganz, MD

UCLA Schools of Medicine & Public Health

Association of Cancer Executives Annual Meeting

January 29, 2014

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Introductory video

http://www.youtube.com/watch?v=gGrj1t_gX2g

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Study Charge

The IOM committee will examine opportunities for and challenges to the delivery of high-quality cancer and formulate recommendations for improvement.

Specific issues reviewed: • Coordination and organization of care• Outcomes reporting and quality metrics • Growing need for survivorship care, palliative care, and

family care giving• Complexity and cost of care• Payment reform and new models of care • Disparities and access to high-quality cancer care

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Study Sponsors

• The National Cancer Institute

• Centers for Disease Control and Prevention

• AARP

• American Cancer Society

• American College of Surgeons, Commission on Cancer

• American Society for Radiation Oncology

• American Society of Clinical Oncology

• American Society of Hematology

• California HealthCare Foundation

• LIVESTRONG

• National Coalition for Cancer Survivorship

• Oncology Nursing Society

• Susan G. Komen for the Cure

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Committee MembersPATRICIA A. GANZ, M.D. (Chair)University of California, Los Angeles  HARVEY JAY COHEN, M.D.Duke University TIMOTHY J. EBERLEIN, M.D. Washington University THOMAS W. FEELEY, M.D. MD Anderson Cancer Center  BETTY FERRELL, PH.D., FAAN City of Hope National Medical Center JAMES A. HAYMAN, M.D., M.B.A.University of Michigan KATIE B. HORTON, J.D., M.P.H. George Washington University ARTI HURRIA, M.D. City of Hope National Medical Center MARY S. MCCABE, RN, MAMemorial Sloan-Kettering Cancer Center 

MARY D. NAYLOR, PH.D., R.N., FAANUniversity of Pennsylvania LARISSA NEKHLYUDOV, M.D., M.P.H. Harvard Medical School MICHAEL N. NEUSS, M.D. Vanderbilt-Ingram Cancer Center NOMA L. ROBERSON, PH.D. Roswell Park Cancer Institute (Retired) YA-CHEN TINA SHIH, PH.D. The University of Chicago GEORGE W. SLEDGE, JR., M.D. Stanford University THOMAS J. SMITH, M.D.Johns Hopkins University  NEIL WENGER, M.D., M.P.H. University of California, Los Angeles 

IOM StaffLAURA LEVIT Study Director

ERIN BALOGHPAMELA LIGHTER

MICHAEL PARKPATRICK BURKE

SHARYL NASSROGER HERDMAN

Original Institute of Medicine (IOM) report issued April 1, 1999

“For many Americans with cancer there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.”

Ensuring Quality Cancer Care

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Ensuring Quality Cancer Care

• Ten recommendations for:• Evidence-based guidelines• Quality measures and electronic data collection

systems• Coordinated, high-quality care, including at the

end of life• Clinical trials and health services research• Access and disparities

• Over past 14 yrs much progress but still many gaps

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Examples of NCPF Workshop Reports

www.nap.edu

“Cancer care is often not as patient-centered, accessible, coordinated, or evidence based as it could be.”

Report concludes that the cancer care system is in crisis

Recommendations for delivering high-quality cancer care

New IOM report releasedSeptember 10, 2013

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Trends Amplifying the Crisis

• The aging population:• 30% in cancer survivors by 2022• 45% in cancer incidence by 2030

• Workforce shortages • Reliance on family caregivers and direct care

workers• Rising cost of cancer care:

• $72 billion in 2004 $125 billion in 2010• $173 billion anticipated by 2020 (39% )

• Complexity of cancer care• Limitations in the tools for improving quality

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The Majority of Cancer Diagnoses are in Older Adults

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The Majority of Cancer Deaths are in Older Adults

Age-specific incidence and mortality rates for all cancers combined, 2006-2010

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18 Million Cancer Survivors Projected in 2022

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Conceptual Framework

1. Engaged Patients

2. Adequately staffed, trained, and coordinated workforce

3. Evidence-based cancer care

4. A learning health care IT system for cancer

5. Translation of evidence into clinical practice, quality measurement, and performance improvement.

6. Accessible, affordable cancer care

Conceptual Framework

Cancer Care Continuum

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Goals of the Recommendations

1. Provide clinical and cost information to patients.

2. End-of-life care consistent with patients’ values.

3. Coordinated, team-based cancer care.

4. Core competencies for the workforce.

5. Expand breadth of cancer research data.

6. Expand depth of cancer research data.

7. Develop a learning health care IT system for cancer.

8. A national quality reporting program for cancer care.

9. Reduce disparities in access to cancer care.

10. Improve the affordability of cancer care.

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Engaged Patients

GOAL 1

The cancer care team should provide patients and their families with understandable information on:

• Cancer prognosis

• Treatment benefits and harms

• Palliative care

• Psychosocial support

• Estimates of the total and out-of-pocket costs of care

Patients Want Involvement

Patient-Centered Care

Incorporation of palliative care across the care continuum

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Recommendation 1• The federal government and others should

improve the development and dissemination of this critical information, using decision aids when possible.

• Professional educational programs should train clinicians in communication.

• The cancer care team should:• Communicate and personalize this

information for their patients.• Collaborate with their patients to develop care

plans.

• CMS and others should design, implement, and evaluate innovative payment models.

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Information in a Cancer Care Plan

• Patient information• Diagnosis • Prognosis• Treatment goals• Initial plan for treatment

and duration• Expected response to

treatment• Treatment benefits and

harms

• Information on quality of life and a patient’s likely experience with treatment

• Who is responsible for care

• Advance care plans• Costs of cancer treatment• A plan for addressing

psychosocial health • Survivorship plan

Substantial differences by age group!

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Engaged Patients

GOAL 2

In the setting of advanced cancer, the cancer care team should provide patients with end-of-life care consistent with their needs, values, and preferences.

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Recommendation 2

• Professional educational programs should train clinicians in end-of-life communication.

• The cancer care team should revisit and implement their patients’ advance care plans.

• Cancer care teams should provide patients with advanced cancer:• Palliative care• Psychosocial support• Timely referral to hospice for end-of-life care.

• CMS and other payers should design, implement, and evaluate innovative payment models.

Tremendous variation in use of hospitals and ICUs at end-of-life!!

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An Adequately Staffed, Trained, and Coordinated Workforce

GOAL 3

Members of the cancer care team should coordinate with each other and with primary/geriatrics and specialist care teams to implement patients’ care plans and deliver comprehensive, efficient, and patient-centered care.

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A Coordinated Cancer Care Team

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A Coordinated Workforce

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Recommendation 3

• Federal and state legislative and regulatory bodies should eliminate reimbursement and scope-of-practice barriers to team-based care.

• Academic institutions and professional societies should develop inter-professional education programs.

• Congress should fund the National Workforce Commission.

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An Adequately Staffed, Trained, and Coordinated Workforce

GOAL 4

All individuals caring for cancer patients should have appropriate core competencies.

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Recommendation 4

• Professional organizations should define cancer core competencies.

• Cancer care delivery organizations should require cancer care teams to have cancer core competencies.

• Organizations responsible for accreditation, certification, and training of non-oncology clinicians should promote the development of relevant cancer core competencies.

• HHS and others should fund demonstration projects to train family caregivers and direct care workers.

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A Learning Health Care IT System for Cancer

GOAL 7

Develop an ethically sound learning health care IT system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings.

Rapid Learning HealthcareData routinely collected in

patient care feed into an ever-growing databank, or set of coordinated databases.

The system learns by routinely and iteratively:

(1) analyzing captured data,(2) generating evidence, (3) implementing new insights

into subsequent care, and (4) evaluating outcomes.

Slide from A. Abernethy

Data collected at the individual patient level informs care for that person, contributes to evidence development and implementation projects at the clinic level, and can be used for large-scale evidence synthesis, CER, discovery, and evidence implementation on health system and higher levels.

Critical elements are: •linked information•motivated individuals and systems engaged to provide reliable integrated information

Clinic level

Health system level

National level

Societal level

A Patient-centered model

Slide from A. Abernethy

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Recommendation 7

• Professional organizations should design and implement the necessary digital infrastructure and analytics.

• HHS should support the development and integration of this system.

• CMS and other payers should create incentives for clinicians to participate in this system, as it develops.

Rapid Learning Cancer Clinic

Conduct CER; analyze data

Implement new evidence

Assess impact of implementation of new evidence; refine

interventions; recurrent CER

Patient-centered rapid learning cancer care

Slide from A. Abernethy

New datasets can be sequentially added, starting at the patient level, with warehousing or federated models. Key element = patient-level linkage.

ePRO data

Rapid Learning Cancer Care

Clinical and administrative data

Clinical trials and research related data

Molecular and biological data

Slide from A. Abernethy

Converging themes

• Comparative effectiveness research (CER)• Healthcare quality• Personalized medicine• Patient-centered care

Application of rapid learning healthcare at the patient level

Slide from A. Abernethy

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Accessible, Affordable Cancer Care

GOAL 10

Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste.

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Recommendation 10• Professional societies should identify and disseminate

practices that are unnecessary or where the harm may outweigh the benefits. 

• CMS and others should develop payment policies that reflect professional societies’ findings.

• CMS and others should design and evaluate new payment models.

• If evaluations of specific payment models demonstrate increased quality and affordability, CMS and others should rapidly transition from fee-for-service reimbursements to new payment models.

http://www.choosingwisely.org/?s=cancer&submit=

Among the 25 things that physicians and patients should question about cancer care…. • Don’t perform PET, CT or bone scans in early stage

prostate cancer• Don’t screen low risk women with CA-125 or

ultrasound for ovarian cancer• Avoid cancer surveillance imaging for recurrence in

almost all cancers (breast, prostate, lymphoma, gyn cancers)

• Don’t perform PSA screening in asymptomatic men with less than a 10 year life expectancy

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Conclusions

• Current US cancer care system is in crisis: aging population, unsustainable costs, fragmentation of care

• IOM report charts a course forward, with many activities already in process

• Heavy emphasis on affordability and reliance on professional societies (e.g., ASCO, ASTRO)

• Payment reform and new models of care are in development— health systems such as those that you work with can lead the way!

To read the report online, please visitwww.nap.edu/qualitycancercare

To watch the dissemination video, please visit www.iom.edu/qualitycancercarevideo

Cover Art “Day 15 Hope,” Sally Loughridge, Rad Art: A Journey Through Radiation Treatment (American Cancer Society, Atlanta, GA)